Dec 8 2023 LPN TTP Jumpstart

welcome

LPN Transition to Practice Jumpstart

to lpn ttpjumpstart

Objectives

REview LPN Transition to Practice Program

Determine Skills for a successful LPN CAreer, including TIme Management, Communication and Nursing Skills

PRactice Communication

• with PAtients,
• in PEer to PEer situations,
• with Clinicians,
• verbal de-escalation techniques

Practice Skills! Including, (but not Limited to)

• Phelbotomy & PIV
• Suture/Staple removal
• Med admin
• Sterile Gloving, Sterile Technique
• Mock Code

Intro to VMG LPN TTP

PHlebotomy & PIV

Intake

Time Management

Agenda

Suture/Staple

CommuNication

MedicationSaFety

LGBTQ patient

Teach BAck

Mock Code

SteRILE Technique

REsources

WELCOME!

1. wHY DID YOU CHOOSE to be a nurse? 2. WHAT WAS THE MOST DIFFICULT THING YOU HAD TO DO IN CLINICAL PRACTICe? 3. Where will you be working?

LPN Transiton To Practice ( TTP) Program

Quality, Safety, and Patient Engagement (On Demand in LMS)

JumpstartIn-person class (today)

Professional Development (On Demand in LMS)

Diversity , Equity, Inclusion (On Demand in LMS)

• 1 Jumpstart AND 3 Quarterly Sessions
• Sessions are NOT sequential

• How to get credit for attendance:

• Complete Redcap survey at the end of each session

Coming Soon!Open Office hours for LPNs

• Watch your email for links to invitations to Educator Open

Office Hours

• Optional
• Drop and leave anytime!
• Chance to drop in & talk about all things LPN or if there are questions

Session Participation

• Speak with your manager to have dedicated time for the sessions

• Sessions will be in LMS

• Log on in a quiet place

• Complete the survey

03

02

01

PATIENT CARE RESPONSIBILITES

LEARNING EXCHANGE MODULES

ORIENTATION CHECKLIST

Orientation Expectations

As you progress through orientation, perform patient care at your current level of orientation, and increase that responsibility throughout the orientation period until you have assumed full patient responsibility.

Ensure the Orientation Checklist is completed in full and submitted by 90 days after start date.

Complete all Learning Exchange (LMS) Modules assigned as part of your orientation; VUMC and department specific.

06

05

04

ORIENTATION MANUALS

END OF ORIENTATION EVALUATION

ORIENTATION FEEDBACK FORM/PROGRESSION TOOL

Orientation Expectations Cont.

You may be asked to complete feedback forms in REDCap with your preceptor to help us understand your skill level and needs during your orientation.

At the end of your orientation, you fill out a final evaluation of your orientation process. This helps us to continually improve our program and meet orient needs.

Review the Orientation Manual for your specific area. This resource contains a plethera of information specific to your clinic service line.

Introduction to ambulatory

Nursing Education & Professional Development

TITLE YOUR SECTION HERE

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Characteristics of the Ambulatory Patient

Roles

Click on people for more information

MEDICAL ASSISTANT

RN

LPN

• Keeps the team in the loop about a the patient's condition, tests, diagnosis, and treatment.

• Serves as point of contact for the patient and helps make sure their treatment stays on course.

• This leads to:

1. Reduced re-hospitalization
2. Fewer appointments
3. Fewer repeated or unnecessary tests
4. The patient saving money
5. Less time away from family and work

What does a Care Coordination and Transition Management Nurse do?

Telehealth

Telehealth nursing encompasses all nursing care and services delivered across distances with the goal of removing time and distance barriers for the delivery of nursing care. Telehealth and telephone triage is an interactive process between nurse and client that involves identifying reason for call, urgency of need, and assessing the next steps. Assessment is made without visual assessment.

A Team Approach

The Clinic Team manages:

• Patient Flow
• Capacity
• Safe Quality Care Environment
• Works Collaboratively to promote EBP
• Assists patients in navigating health care goals at home

Let's take a look at intake

Intake

Intake

Intake

How did Ruth do?

Let's try that again..

Intake

Intake

Intake

Quality Intake Screenings

On Every

Left Side Is Required

Highlighted in RED

Right Side Is Checklist

Discharge & Checkout

• Complete visit by giving any meds/vaccines and performing

ordered procedures (ie labs, tests)

• Explain After Visit Summary
• Follow appointments/education/etc are listed
• Clean Room
• Send to "checkout" in eStar to remove from whiteboard

Patient Centered Care

Patient and family centered care is working with patients and families, rather than just doing to or for them. People are treated with respect and dignity. Healthcare providers communicate and share complete and unbiased information with patients & families in ways that are affirming and useful. Patients are encouraged & supported in participating in care and decision making at the level they choose.

Patient Centered Care

At Vanderbilt

We are committed to defining personalized care that is: For YOU Near YOU Knows YOU

Evidenced Based Practice

integrates current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.

AAACN

The American Academy of Ambulatory Care Nursing standardizes and defines the scope of practice in Ambulatory Care Nursing by:

• Offering networking and collaboration

• Providing educational opportunities & professional development

• Providing multiple learning opportunities

Vanderbilt

Clinics In Nashville area and beyondSpecialties

• Mulitple specialties from Heart, Cancer Center, Primary Care, Orthopedics, Dermatology, Surgery, Rheumatology, etc.

States

• Tennessee, Alabama, and Kentucky

Over 140 Clinic Locations & Growing!

Phlebotomy and PIV INsertion

Objectives

• Verbalize importance of aseptic technique
• Demonstrate proper phlebotomy technique
• Understand different types of blood specimen tubes and requirements
• Demonstrate proper technique for removing PIV

Blood Specimen Collection: Venipuncture Vacuum-Extraction Method (Ambulatory)

(3:50 minutes)

Phlebotomy Site Contraindications

Avoid areas of:

• Hematoma
• Phlebitis
• IV infiltration
• Side of mastectomy / node removal / tumor
• Lymphatic compromise
• Exposure to radiation
• Tissue injury
• Affected side of stroke
• Dialysis shunt/fistula

Phlebotomy

• Verify lab order, scan ID Band (2 identifiers)

• Review record for latex allergies, bleeding risk, adverse reactions, site contraindicators.
• Gather supplies (check expiration dates).
• Hand Hygeine

• Apply tourniquet several inches above potential site.
• Do not leave on longer than 1 minute
• Avoid contraindicated sites.

• Release tourniquet, H/H, don clean gloves.
• Cleanse site (basket weave motion), air dry.

• Re-apply tourniquet
• Gently apply downward pressure below chosen site with thumb/forefinger to pull skin taught and stablize vein.
• Insert needle (bevel up) at approximately 15 degree angle.
• With flash of blood, stabilize needle / do not advance.
• Advance collection tube to pierce rubber tube top and collect required blood samples.

• Gently invert each tube back and forth if tube contains additives (do not shake).
• Release tourniquet on last vial drawn.

How to draw blood

Phlebotomy

• To withdrawal phlebotomy needle, lay a sterile 2 × 2-inch gauze pad on the venipuncture site.
• Withdraw the needle, activating the needle safety mechanism.
• Exert pressure and hold for 3-5 minutes based on bleeding risk.
• Those on anticoagulant therapy have increased bleeding times.

• Discard the collection barrel, needle, and tubing into sharps container.
• Never recap needle!

• Apply tape / band aid pressure dressing / elastic wrap (coban) per facility protocol.
• Instruct patient to leave in place for 15-60 minutes.

• Label the specimen in front of patient and verify all information with them.

• Remove gloves and H/H.

Care of site

Phlebotomy

Order of blood draw

Peripheral IV Insertion

• Evaluate patient, evaluate arm

• Select vein, catheter gauge

• Tourniquet and CHG site

• Venipuncture - bevel up, shallow angle

• After flashback - advance CATHETER ONLY

• Remove needle - attach tail and flush

• Remove syringe and secure IV with dressing

PIV Insertion Training Video

practice Phlebotomy and PIV skills

Priorities

Teamwork

Time Management

Delegate

Objectives

Describe time management strategies in the ambulatory setting

Examine ways to prioritize your workday

Determine how to delegate tasks

Summarize how teamwork creates a better patient experience in clinic

Plan Your Day

Establish a Routine

Attend Huddles

Prepare for Work Day

Time Management Skills

During your first year of practice, as skills develop:

• Skills improve due to repetition
• Time to learn new things
• Ability to take on more responsibilities

Time Management Skills - Routinization

• Tasks that are repeated in the same order each time
• Helps for anticipating supplies, cutting down on extra trips
• Reduces "thinking time"
• Can be altered as needed

Divide and conquer

Time Manage-ment

Organize materials

• Break up tasks into smaller tasks

• Give tasks a reasonable deadline

• Do things yourself if you can

• Don't be too hard on yourself - it takes time to learn new skills

• Listen to your patients!

• Personal calls/texts, gossip, checking personal email

Ignore interruptions

Take time to learn

now, not tomorrow

Opportunity is knocking

watch for time gobblers

Prioritize using: C.U.R.E.

How do you prioritize care?

Hover over letters for more information

Prioritize Your Work

• Some tasks will not be as easy as these examples
• Stay calm
• Think clearly
• Ask for help when you need it

Delegation

Delegation: THE Process for a Nurse to Direct anothe rperson to perform Nursing Tasks or Activities

Involves 2 people: Delegator and Delegatee

the 5 Rights of Delegation (ANA)

• 1. RIght Task -
• which tasks are appropriate
• 2. Right Circumstance -
• Does the delegatee have the right resources and Supervision if needed
• 3. Right PErson -
• Does the Delegatee have the right Training and Experience
• 4. Right Supervision -
• Does the Delegatee need supervision, if so by whom
• 5. Right Direction and Communication - next slide

The Five Rights of Delegation

Specify

Identify and Review

Explain

Acknowledge

STATE

Identify/review priorities Example: Dr. Whitecoat has two extra patients worked in today, so we need to be as efficient as possible.

Explain how you are monitoring the white board for patient status and throughput Example: I am working on getting the outside labs for these two patients

Acknowledge expertise of person you are making this request of Example: You really do an execellent job at intake.

State exactly what you are delegating and expected outome Example: Rachel, can you please get Dr. Whitecoat's next patient, Mr. Green and do the intake?

Specify any limitations, deadlines or resources Example: We have two other providers in clinic today, so we need to turn the rooms over as quickly as possible

Barriers to Delegation

Want to take responsibility for everything yourself

Uncertainty about rules and regulations

Others don't want to let go of tasks or lose control

Fear of taking risks

Reliance on habits or prior experiences

Lack of trust of coworkers

4 p'sfor working on a team

Purpose

Why is the patient in the clinic today?

Picture

Plan

Clinic Staff

What are expected outcomes of this visit

How will the team work together?

Part

What part do I play In this patient visit?

Communication in Ambulatory

Objectives

• Overview of effective communication
• Discuss telephone communication
• Service Recovery
• Understand Cultural Competence related to communication
• Recognize and understand Patient education teach back

What is AIDET?

A-Acknowledge I-Introduce D-Duration E-Explanation T-Thank

VUMC encourages us to use AIDET to introduce ourselves as professionals, begin interactions, and de-escalate situations (Service Recovery)

First Impressions

Body Language is communicated upon intake in the clinic setting

Facial expressions can tell a story to your customer.First impressions inspire others to trust you, cooperate with you and lead to positive outcomes.

VUMC Culture of Service

Telephone Communication

Staff can communicate effectively by:

• positive interactions
• Working together as a team
• body language has the largest impact on one's ability to effectively communicate (55%)
• followed by tone of voice (38%)
• and word choice (7%)
• during phone communication, tone of voice has the largest impact (86%)

We can elevate our culture of Service by striving for exceptional service by:

• Be welcoming: 7 seconds to create a first impression!
• Acknowledging others by smiling
• Being present : Avoid distractions
• Calling people by their names : Address patient & families by Mr. or Ms. unless they instruct differently

Tips

Smile.

Your body language and tone of voice communicate your compassion. A smile can be seen and heard.

Feedback.

Listen and provide feedback to indicate that you are listening. verbal cues to ensure you are listening “Ok sounds good” or “Ok I got it…”

Clarify.

Clarify & ask appropriate follow up questions.Cultural Considerations

HEARD

“The doctor is currently running behind due to a complication. He is spending quality time with that patient and will be sure to do the same for you as well.” Respond to the problem, setting timelines and expectations for follow-up

“I appreciate your honesty and sharing your frustration, I truly apologize for the delay in time…”- Acknowledge and apologizing takes ownership of problem Very important to customer

“I understand this must be frustrating for you…” Empathizing creates an emotional connection with patient

Deliver! Take action. You may need to document or delegate to the appropriate person: -Does it need to be documented / or a vertias filed? - Resolve the issue. - Prevent it from happening again.

Remember....

Interpreter Services

• Provide onsite, telephone, and/or video resources​
• 24-hour access
• account number & pin from badge card, or on a phone in your clinical area
• Website for interpreter services available
• When a Limited English Proficient patient schedules an appointment, Interpreter Services receives an automatic interpreter request
• if onsite interpreter not available: mandatory that staff use a video or phone interpreter. do not make the patient wait for onsite interpreter

Lateral Violence (Peer to Peer )

Team issues...Words to help

Strategies for Responses

Non verbal innuendo (rolling eyes, face-making, etc)“I see from your facial expression that there may be something you wanted to say to me. It’s okay to speak directly to me. (I would prefer it.)” Verbal affront (snide remarks, lack of openness, abrupt/angry responses)• “The people I learn the most from are clear in their feedback. Is there some way we can talk this through?” • “What happened?” Undermining activities (turning away, not available) • “What has happened? Have I done something that irritates you?”Withholding information (practice or about patient) • “I believe that there was (is ) more information available regarding this situation and I believe if I had known that (info), it would (will) affect how I learn or need to know.”

Cognitive REhearsal a way to mentally prepare to address threats from INcivility or Bullying

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 77-84. • Griffin, M., & Clark, C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal Of Continuing Education In Nursing, 45(12), 535-542 8p. doi:10.3928/00220124-20141122-02

Lateral Violence (Peer to Peer )

Team issues...Words to help

Strategies for Responses

Sabotage (deliberately setting up a negative situation). • “There is more to this situation than meets the eye. Could “you and I” (whatever, whoever) meet in private and explore what happened?” Verbal affront (snide remarks, lack of openness, abrupt/angry responses)“Infighting (bickering with peers). Nothing is more unprofessional than a contentious discussion in non-private places. Always avoid. • “This is not the time or the place. Please stop” (physically walk away or move to a neutral spot).Scapegoating (attributing all that goes wrong to one person). Rarely is one individual, one incident, or one situation the cause for all that goes wrong. . • “I don’t think that’s the right connection.” Backstabbing (complaining to others about an person and not speaking directly to that person). • “I don’t feel right talking about her/him/situation when I wasn’t there, or don’t know the facts. Have you spoken to her/him?”

Cognitive REhearsal These strategies can be used with anyone on your team. Write and Save!

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35(6), 77-84. • Griffin, M., & Clark, C. M. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal Of Continuing Education In Nursing, 45(12), 535-542 8p. doi:10.3928/00220124-20141122-02

Verbal De-escalation

Patient EscalationWords to help

Strategies for Responses

Cognitive REhearsal WOrks! Write and Save!

Suture & Staple Removal

Objectives

• Demonstrate technique for suture and staple removal

• Demonstrate cleaning of wound

WOUNDS

Suture and Staple Removal: General timing

Do not remove unless instructed to.

Removing Staples, Sutures, and Steri Strips

(5:47 minutes) Either watch video or proceed to next slide to explain as you go.

Staple Removal

• Sterile staple remover kit.
• H/H and don clean gloves.
• Clean staples and incision area with NS / antiseptic swabs (per organzation's practice.

• Place TWO lower jaws of the staple extractor under the first staple to be removed.
• Depess the upper handle of extractor fully down.
• Extractor will bend the center of staple downward and ends upward. (BAT WINGS)

• Lift the extractor straight up.
• Discard staple.

• Remove every OTHER staple. If incision intact, remove all staples.

• Cleanse area per protocol.

• Document # of staples removed.

Suture Removal

• Sterile suture removal kit.
• H/H and don clean gloves.
• Clean sutures area with sterile antiseptic swabs / NS (per organization’s practice).

• Place sterile gauze close to suture line. Grasp sterile scissors in dominant hand and forceps in nondominant hand.

• Grasp suture KNOT with the forceps and gently pull it up. Slip tip of scissors under suture.
• Cut suture as close to the skin as possible and distal to the knot.
• With forceps, pull suture from skin.

• Place removed suture on gauze.

• Remove every OTHER suture. If incision remains intact, remove all sutures.

• Clean area per protocol.

• Document # sutures removed

Cleaning Wound After Removal

Placing Medical Tape (Steri-Strips)

• You may need to apply medical tape strip to healing wounds after suture / staple removal:

• Remove every other suture/staples first, so wound does not seperate.

• Replace suture/staple with steri strip.

• Continue same process until all sutures / staples have been removed.

Removing Medical Tape (Steri-Strips)

To remove tape strip:

• You may apply adhesive remover at the ends of each strip in order to grasp the edges.

• With forceps or fingers, gently grasp one end of each strip by peeling end toward the wound. Repeat at opposite end of each strip.

• Once both ends are free (up to the incision area), gently remove the strip from skin.

https://point-of-care.elsevierperformancemanager.com/skills/19315/quick-sheet?skillId=AM_098&virtualname=vuebl-tnnashville

Passcode: L1TXCF&5

Teach Back

Why?

What?

How?

VIDEO 1

TEACH BACK

HERE'S AN EXAMPLE OF WHY TEACH BACK IS SO IMPORTANT!

Tips to Initiate Teach-back

Sound conversational, put the burden on your shoulders. "I want to make sure I explained things clearly." "If you were explaining to your spouse how to take this medication, what would you say?" "Tell me, what are 2 things are you changing in your diet?"

Tips to Initiate Teach-back cont.

Don’t end your conversation with “do you understand?” Patients may answer “yes” even when they don' t understand Ask open ended questions. "What questions do you have for me?"

Teach-back Example

New Prescription

Assess patient/caregiver’s understanding of:

• need for medication
• side effects
• dose
• how often to take

How am I going to teach my patient?

Ask patient to repeat in their own words what they have learned. How well did I explained it.

Check for understanding

Close the Loop May need to repeat instructions or clarify

Chunk Group information into 3-5 points

Activity: Teach-back

Instructions:

• Divide up into groups
• Identify a teacher and a learner

• Review handout and choose what learner should take away from activity
• Teach this information and verify knowledge
• Discuss as a group

Education Documentation

Document Learning Assessment

Education Documentation

Vanderbilt Resources

When you get to your clinic - bookmarK: vumc.org/vanderbilt-nursing/quick-links

• Links you to:
• My workday
• Elsevier (patient education and skills)
• Krames (patient education)
• Veritas (incident reporting)
• Learning exchange
• Policytech
• Click Employee Resources and find product resources
• And much much more!

Clinical references in eStar

Krames - patient education

Medication Safety in Ambulatory Clinics

2023

OBJECTIVES

• Review Medication Reconciliation
• Review medication administration safety practices
• List factors that influence medication errors
• Identify routes/sites of medication administration and practice skills
• Demonstrate how to label medications
• Identify the top 10 medications patients take
• Resources
• Documentation review

GOAL: Safe practice and accountability with all medication administration.

Medication Reconciliation

5+ rights of medication administration

· Right Route

· Right Patient

· Right Time

· Right Medication

· Right Dose

· + Documentation

BAR CODE MEDICATION ADMINISTRATION (BCMA)

Minimizes medication errors Improves patient safety improves quality of care

Ensure ID Band is secured on patient. Verify with patient correct name and date of birth and compare to ID band.

• Verify patient consent for medication

• Inspect medication for any tampering, opened packages, discoloration, particulates, exposure to fluid, etc

• Verify patient allergies

If patient has a history of serious reaction or allergy to the medication - STOP - DO NOT ADMINSTER and report it to RN or Provider

ID Band does not belong on the clipboard!

BAR CODE MEDICATION ADMINISTRATION (BCMA)

1. SCAN PATIENT 2. SCAN MEDICATION 3. VERIFY MAR

Troubleshooting BCMA Scanners

There should be a card / paper near your workstation with the directions. You may 'test' the scanner after re-setting by scanning the example medication barcode.

You are responsible for all aspects of your medication administration

• Correct administration of medications (per VUMC policy)

• Clarify!! Discuss any concerns with prescribing Provider or RN

• Educate patient about potential adverse reactions

• Correct documentation

Medication Storage and Labeling

Labeling

Clinic Storage

Omnicell (automated dispensing cabinet

• Patient name
• Medication name
• Dose
• Route
• Volume
• Expiration date and time

Locked cart or cabinet

ONLY remove medications for one patient at a time.

medication labeling

Immediately Administered Meds

Not Immediately Administered Meds

• Applies when transferring from original medication container to a different medication container (ie drawing med from vial)
• Prepare medication
• Take directly to patient
• Administer to patient without any break in process
• Not required in procedural areas: Patient name, location, expiration date, time

• Applies when transferring from original medication container to a different medication container
• Discard any unlabeled or partially labeled medications
• If giving multiple medications, remember to label one med at a time
• Verify all medication labels verbally & visually with two qualified staff members
• Two person verification required prior to relief for break, lunch or end of day

VS

Label Requirements

Standard pre-printed labels are available through Vanderbilt Printing Services (MC# 0815) Blank label can be used with all requirements documented Requirements are highlighted on this pre-printed label

Medication Labeling additonal info

Do not pre-label empty containers. Apply label immediately before or after filling new container

Check the Expiration Date or Beyond Use Date: Day/time beyond when the product should not be administered or used on a patient. Do not tape the original medication container to the new container.

high alert medications

Medications that may cause patient harm if administered incorrectly

Require separate independent double check of all patient rights

Name medication rights that you would need check prior to administering

Name medication types that would alter monitoring period

Name patient conditions that would alter monitoring period

What are other indications for monitoring after a high alert medication include (vital signs, etc.)

Name routes of administration that may alter monitoring period

Monitoring patient post administration

Duration & frequency based on:

• Patient condition
• Medication type
• Route of administration
• High alert medications

patient/family education

Krames:Example: Search “Influenza”

• Multiple tabs appear
• Click on Alchemy Drug Sheets
• Sample of teaching documents in English and Spanish

Adverse reactions

Respiratory

Cardiovascular

Skin

Swelling of lips or tongue, trouble breathing, wheeze, cyanosis (turning blue)

Rash, itching, flushing

Decreased Blood Pressure, fainting, dizzy

Anaphylaxic Emergencies

Know where your clinic keeps its Anaphylaxis Kit. It should be near where the medications are stored If your clinic does not have a kit, ask your manager to request one from pharmacy

name some common routes of med administration

subcutaneous Injections

• Subcutaneous Injection Sites
• Choose appropriate needle size and length for patient and syringe type
• Pinch or Non-pinch option
• Search for "Medication Administration: Subcutaneous Injection (Ambulatory) in Elsevier

IM DELTOID (Adult) ADMINSTRATION

Clean site thoroughly with alcohol and allow to dry

1. Administer the vaccine straight into the slected site at a 90 degree angle
2. Do NOT aspirate
3. Activate the safety mechanism on the injection needle and discard into sharps container
4. apply bandage or tape with gauze to the injection site
5. Perform hand hygiene and document as appropriate

• Check patient's bleeding risk prior to injection

• Never give higher than 3 finger widths below Acromion Process

• Prepare paitent for injection so they do not jump or pull away during administration

im injection sites

Rectus femoris & vastus lateralis

Deltoid

Ventrogluteal

• Lying on side or back
• Have patient flex knee and hip to relax

• Standing or sitting

• Sitting or lying with the toes gently point away to relax the muscle.

• Identify acromial process
• Place 2-3 fingers from this location

• Place base of one hand over greater trochanter of femur and base of other hand over the kneecap
• In space between fingertips, injection should be placed on lateral or anterior surface, in upper two-thirds of thigh

• Identify greater trochanter of femur

• Place base of the hand over this
• Reach toward iliac crest, so the forefinger is toward or touching the iliac crest, spread fingers apart
• Inject at the "V"

DO NOT ASPIRATE

Shoulder Injury Realted to Vaccine Adminstration (SIRVA)

SIGNS AND SYMPTOMS:

• Serious shoulder pain and less range of motion (unable to move your shoulder normally).
• The symptoms usually show up within 48 hours after you get a vaccine shot in your upper arm.
• Over-the-counter pain meds don’t help the symptoms get better.

HOW DOES IT HAPPEN:

• SIRVA can happen if a medical worker gives you a vaccine shot too high up on your upper arm.
• This can accidentally damage tissues or structures in the shoulder.

WHY DOES IT HAPPEN:

• The vaccine shot can go into the wrong part of your upper arm or trauma can occur from the needle. This brings on inflammation, and it could injure:
• Ligaments - tough bands of tissue connecting two bones in a joint
• Tendons - thick cords that connect muscles to bones
• Bursae -fluid-filled sacs cushion bones, tendons, and muscles

In rare cases, you can get an injury known as SIRVA from vaccine adminstration.

To prevent SIRVA and give these shots properly, medical workers are trained to look or feel for specific physical “landmarks” on the arm that guide them to the deltoid muscle. Never take short cuts. Always utilize the IM Deltoid Landmarks whenver giving vaccines.

https://www.webmd.com/vaccines/what-is-sirva

CAUTION: Fainting can occur after adminstering vaccine

Signs/symptoms of reaction:

• Changes in breathing
• Wheezing
• Hives
• Swelling
• Weakness
• Change in Blood Pressure
• Change in Level of Consciousness

COVID vaccinations must be monitored (adverse reactions) for 15 minutes!

Skills

• Practice IM and SC injections

pediatric Intramuscular sites & volumes

pediatric subcutaneous sites & volumes

medication resources

• Lexicomp
• Can access from eStar from the medication in MAR

medication resources

• Lexicomp can be accessed on side bar when in Home Meds

medication errors - other factors

• Multiple professionals from different roles involved
• Poor lighting
• Inadequate staffing patterns
• Poorly designed medical devices
• Handwritten orders
• Trailing zeroes (e.g., 2.0 vs. 2) or using a decimal point without a leading zero (e.g., .2 instead of 0.2)
• Misinterpretation of such an order can result in a 10-fold dosing error!
• Ambiguous drug labels
• Lack of an effective independent double-check system for high-alert drugs
• Medication cabinet over-rides

LPNs may not administer IV push medications, thrombolytic infusions, or chemotherapy

VUMC Medication Administration Policy Number MM 10-10.01

Regional Policy permits IV push after 6 month experience, completion of IV course, and supervision of Provider or RN

References

• “10 Most Popular Prescriptions.” GoodRx, Jan. 2020, www.goodrx.com/drug-guide .
• Elsevier Clinical Skills
• Grissinger, Matthew. “The Five Rights: A Destination Without a Map.” Pharmacy and Therapeutics, MediMedia USA, Inc., Oct. 2010, www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/.
• Le, Jennifer, et al. “Drug Administration - Drugs.” MSD Manual Consumer Version, 020 Merck Sharp & Dohme Corp., a Subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, June 2019, www.msdmanuals.com/home/drugs/administration-and-kinetics-of-drugs/drug-administration.
• Policy: High Alert Medication VUMC https://vanderbilt.policytech.com/dotNet/documents/?docid=15806
• Intravenous Medication Administration https://vanderbilt.policytech.com/dotNet/documents/?docid=10641
• Policy: Medication Administration VUMC https://vanderbilt.policytech.com/dotNet/documents/?docid=15991
• “Prescription Drug Information, Interactions & Side Effects.” Drugs.com, Drugs.com, www.drugs.com/.
• Medication Labeling: Outside of Pharmacy https://vanderbilt.policytech.com/dotNet/documents/?docid=12460
• U.S. Department of Health & Human Services. “Adult Immunization Schedule by Vaccine and Age Group.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Feb. 2020, www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.
• https://www.medicinenet.com/top_drugs_prescribed_in_the_us/views.htm
• https://www.webmd.com/drug-medication/news/20150508/most-prescribed-top-selling-drugs
• https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/default.aspx

sterile technique

Objectives

• Recognize sterility of supplies
• Demonstrate opening a sterile field
• Demonstrate adding to a sterile field
• Demonstrate putting on sterile gloves
• Understand process for 'Time-Out'

Wrapped pan - how do I know it is sterile?

• Load sticker present
• Date of sterilization
• Autoclave number
• Load number
• No sticker = not sterile
• Tape stripes dark brown (changes color with sterilization)
• No signs of moisture
• Integrator line is dark in the accept region

• Item may have a water-resistant cover
• Validate cover is intact without tears or signs of moisture

Sterile Instruments, sterile packs

• Instruments in peel pack, free of punctures, moisture or tears.
• Indicator changes to dark color to indicate sterility
• No holes, tears, or signs of moisture
• Expiration date current

• Indicates single use and can be disposed of properly (in sharps/redbag/etc)

Opening a Sterile Package

(1:49 minutes)

opening sterile commercial wrapped packages

• Place the sterile kit on a clean, flat work surface. Items placed BELOW level of the sterile field are considered NONSTERILE.
• Open the outside cover of the kit and remove the kit. Discard outside cover.

• Grasp the tip of the outermost flap of the kit, and open it AWAY from the body, keeping arm outstreched. Do not reach over the sterile field.
• Grasp the tip of the first side flap, and open it by pulling it to the side and allowing it to lie flat on the table surface. Keep arm to the side and not over the sterile field.
• Grasp the tip of the second side flap, and open it by pulling it to the side and allowing it to lie flat on the table surface. Keep arm to the side and not over the sterile field.
• Grasp the outside border of the last (innermost) flap. Stand AWAY from the sterile package and pull the flap TOWARD the body, allowing it to fall flat on the table.

• NEVER REACH OVER A STERILE FIELD.

https://point-of-care.elsevierperformancemanager.com/skills/19319/quick-sheet?skillld=AM_090#scrollToTop

Sterile Drape or Towel

• Gather supplies and determine integrity of packaging / expiration dates.

• Perform hand hygiene.

• Don clean gloves.

• Sterile field must be set up on a tray or table that is at least waist high

Sterile Drape or Towel

• Place package containing the sterile drape on a clean, flat work surface and peel back outer covering of package.

• Pick up the folded edge of the drape with fingertips of one hand. Lift drape away from wrapper and allow drape to unfold while keeping it above waist and away from the body.

• Do not allow drape to touch any surface while unfolding.

Position bottom half of drape over the top half of the work surface.

Allow top half of the drape to unfold over the bottom half of the work surface.

Grasp adjacent corner of the drape with the other hand and hold drape straight over the work surface.

1 inch border is considered NOT-STERILE

Adding Items to the Sterile Field

• Do not hold arm over sterile field.
• Ensure wrapper does not fall on to the sterile field or let the edges of wrapper touch the sterile field.
• Discard the outer wrapper.

• H/H.
• Don sterile gloves to handle sterile supplies if needed.

• Step back slightly from sterile field.
• Open sterile item while holding outside wrapper in the nondominant hand.
• Use dominant hand to peel wrapper back over the non dominant hand.
• Drop the enclosed sterile item onto the field at an angle.

Adding Liquid to the Sterile Field

• Verify solution and the expiration date.
• Place a sterile basin on edge of the sterile field.

• Remove the seal and cap from the bottle in an UPWARD motion and discard.
• Hold bottle with the label facing the palm of the hand.
• Step back so clothing does not touch sterile field.

• With the bottle held away from the field and the bottle lip held ABOVE THE INSIDE OF THE CONTAINER, slowly pour the solution into the container.

• Do not spill on the sterile field or it will be considered contaminated!

• Do NOT recap the bottle.
• Discard any remaining liquid.

Donning Sterile Gloves

• Use soap and water - scrub all surfaces of hands to mid forearm - 20 seconds
• 20 seconds = Singing

'HAPPY BIRTHDAY' or 'ROW ROW ROW YOUR BOAT' - TWICE

Perform Hand Hygiene past wrist to mid-forearm

YOUR GLOVES ARE NO LONGER STERILE IF YOUR SLEEVES OR WATCH/BRACELET TOUCH THEM!

Prior to Donning Gloves:

• Remove watch/bracelets and any large jewelry (rings with stones).

• Remove jacket and if long sleeve shirt, push sleeves up and secure above elbow

After Donning Sterile Gloves:

• Maintain sterility of gloves by interlock fingers of both hands.

• Keep hands above waist at all times.

(2:26 minutes)

Open package and identify right and left glove.

Remove outer glove package wrapper.

With gloved hand, slip fingers inside cuff of the second glove, lift and insert non-dominant hand. You may now reposition fingers if needed.

Pick up glove of dominant hand at the cuff with thumb and first 2 fingers of non-dominant hand and pull on glove. Do not fix fingers if misplaced.

Assisting With Sterile Procedure

Mask (with faceshield)

Sterile Gloves

You may be asked to assist a provider or nurse with a sterile procedure. Be prepared to:

• Don appropriate sterile or clean coverings
• Hold patient or equipment
• Add items to the sterile field

Gown (Protective or Sterile)

MAINTAINING STERILITY

Interlock the fingers of gloved hands.

Keep hands above waist level and in front of you at all times.

Touch only sterile areas or items.

Do not reach over the sterile field.

Do not turn your back on the sterile field.

"TIME OUT"

Universal Procedure - Time Out

• Verify correct patient, procedure, and site

• Minimizes risk of performing incorrect procedures

• Applies to all invasive / surgical procedures
• Consists of:

• Pre-procedure verification - match procedure, treatment, supplies to the correct patient (involve patient if possible)
• Site / side marking (as applicable)

• Performed immediately prior to the procedure or incision

• Correct patient identity
• agreement on procedure to be done per consent documentation
• confirmation that correct site is marked (if applicable)
• If using electrosurgery, cautery, or laser:
• Site is dry prior to draping or use of surgical equipment
• No pooling of solution and solution soaked materials are removed from ignition sources

practice skills

VUMC Nursing Professional Development

Clinic Emergency Response!

Emergency Situations

• VUMC patients tend to have a higher acuity, which increases the probability for an emergency

• During an emergency, the environment may be uncontrolled and need order

• Emergency situations may occur anywhere including waiting rooms, hallways or exam rooms

• Handling emergency situations is specific to each clinic and equipment that is available

VMG Code Response

• Response Team on campus or

• ED Paramedic response for non-inpatients

• Assess the situation

• Stabilize the now patient

• Transports to ED as a new patient

• Call 1-1111 to activate on campus or 911 on campus

• Stay with the patient

Mock Code Training Benefits

• Enhances teamwork

• Ensures staff competency

• Increases staff comfort

• Increases staff confidence

• Decreases staff anxiety

• Leads to improved clinical outcomes for patients

Wilson, B.L., Phelps, C., Downs, B.,& Wilson, K. (2010). Using human factors engineering in designing and assessing nursing personnel responses to mock code training. Journal of Nursing Care Quality, 25 (4), 295-303.

• Team leader

• Call 1-1111 or 911

• Direct emergency personnel to patient

• Assess need for CPR

• Perform chest compressions

• Manage the airway

• Get emergency equipment and supplies

• Run AED

• Start IV if this is a skill of the clinic

• Support family

• Manage other patients/visitors in the waiting room or care area

• Document event on paper arrest record, then upload to the chart

Group Activity: Identify Roles for BLS staff vs non-BLS staff

Arrest Record

The square code is for indexing in the EMR

This form is found with crash carts and sometimes with AED. It can be printed from Medex by PSS during code.

Debriefing after a Event

• Information shared honestly. Not used as a blame session.

• Discuss what went well and identify areas for improvement.

• Discuss facts, why actions and decisions were made in the moment.

• Discuss feelings and resources available (Employee Assistance Program (EAP) for individualized counseling)

Research shows debriefing improves team performance in emergency response outcomes.

Summary

• Emergency situations are more likely in some VMG clinics due to increased patient acuity

• Identifying staff roles prior to an event increases the efficiency of an emergency response

• Documentation of an emergency event is required on the arrest record printed from the patient chart and uploaded into eStar

• Planning and preparing the team in the event of an emergency improves patient outcomes

• Debriefing after a simulated or real event allows staff to identify areas of improvement and to discuss their feelings

SkillPRactice

Mock Code

References

• Boshers, Kim C. “3 Elements of Debrief.” 6 Dec. 2019.
• PolicyTech: Adult Emergency Department Standard Operating Procedure -Tiered Response
• PolicyTech: Policy: Cardiopulmonary Resuscitation (CPR)
• Rodgers, David L, and Tammi Bprtmer. Debriefing ACLS and PALS with the AHA Structured and Support Debriefing Model , 2015, Website Reference
• Salas, Eduardo, et al. “Debriefing Medical Teams: 12 Evidence-Based Best Practices and Tips.” The Joint Commission Journal on Quality and Patient Safety, Elsevier, 16 Nov. 2016.
• Vanderbilt University Medical Center MEDICAL EMERGENCY PLAN

Use your Resources

Say Something

Employee Assistance ProgramCommon concerns: Depression, relationships, life stressors, workplace

Elsevier

Your Clinic's Nurse Educator

Google: VUMC Nursing Links! (www.vumc.org/vanderbilt-nursing/quick-links)

Nurse Mentoring – Located Under Professional Development

• After you click on the link, complete the RedCap Survey
• Select you are interested in being mentored

Requesting a Mentor

Thank you!

https://redcap.link/js25zlr6